I'd like to make two comments. The first draft
of the document to be used in Beijing for the International
Women's Conference did not contain the word breastfeeding. Now,
how can you write a document about women and empowerment of women
and not even mention it? I understand that it has now been
included.

Van Esterik

No. I was at the preparatory conference, and I
welcome a chance to bring you up to date. The fascinating thing
is that breastfeeding was there in the regional conferences in
South-East Asia and Latin America and the Vienna Conference on
Human Rights. Breastfeeding was very clear because the World
Assistance for Breastfeeding Action (WABA) lobbied to make sure,
and it went in under "women's health," "human
rights," and "employment," so that if it was
removed in one section, it would be there in another. When those
drafts came to New York, every reference to breastteeding was
removed. So we went to the preparatory conference for Beijing and
we lobbied, and we know for sure that one reference is in under
"structural adjustment," because one of our WABA
members is the Swaziland representative, and she stayed up until
midnight when they were finishing, and she got it in there. But
all the most important places-"human rights,"
"women's health," and "infant health"-were
bracketed, which means they will not be discussed until Beijing.
That document was not out until the last day of the preparatory
conference, and so we have a lot of work to do.

Bishop McHugh

I agree. But I also think it underscored part
of my concern, and that is, it is part of a cultural context that
eliminated it. When the documents came to New York, it was a
different understanding of women that is perhaps local to ten
square blocks of New York City that wrote the document and
excluded that concept, because that's not part of their lexicon.
The second comment I want to make is that you did not have to
feel uncomfortable showing the Playboy pictures. In fact it's
important to show them, because we in the United States face
recurring court cases brought by women who have been excluded
from restaurants or other places for breastteeding. They have to
go to the courts to vindicate what seems to me ought to be a
natural right. But you can walk into any drugstore, and what you
have is mild compared with what you can get from the so-called
girlie magazines.

Dr. Sommerfeldt

Just a very brief comment on the Women's
Conference in Beijing. I had a call from someone from New York
asking if the Demographic and Health Survey could give an
estimate of the burden that breastfeeding imposes on women. I
think the reason for this question was to support an argument
that it was difficult to breastfeed and perhaps that women
shouldn't do it. I said that, first, I didn't think it was a
burden. Second, I said there was no way we could provide that
kind of quantification, although all they had to do was pick up
our report and take whatever information they wanted from it. I
also said that if a woman didn't breastfeed and didn't use
contraception and conceived again very soon, that would be a much
greater burden on her than breastteeding. She never contacted me
again. Maybe she got an answer from someone else. I don't know.

Dr. Van Esterik

We had a major problem. The Health Caucus was
controlled by someone who was very close to multinational
companies, and we had BINGOs (Business Interest NonGovernmental
Organizations) in that caucus, not women's interests NGOs. One
thing that made it very difficult was that they went around to
some people we were lobbying and talked about how people who were
promoting breastfeeding were just trying to make women feel
guilty if they couldn't breastfeed. They kept asking other people
for statistics about how many women couldn't breastfeed. I will
leave you with a popular article, as well as an academic one,
arguing that breastfeeding is a feminist issue. The first is
designed specifically for radical North American and European
women's groups that do not usually think about breastfeeding, and
the second is to tell them why they should consider breastfeeding
as a feminist issue.

Dr. Menken

I think we would be unrealistic if we said that
breastfeeding was not a burden. It is a burden if women are
hassled in the ways that we have been talking about. It's made a
burden, and I think that's exactly the kind of point we are
addressing. These are burdens caused by culture, and many of the
issues we need to address are making it comfortable, promoting an
atmosphere, just as many people live in an atmosphere where their
attempts to breastfeed are frowned upon and discouraged. My first
kid was born in Bethesda Medical Center. Let me tell you, the
fight to breastfeed 29 years ago was really something. Not many
people have the energy. They are fighting too many other battles.
What we need to say is that under the right circumstances, it is
not a burden; it's much better, and it's much easier, but I think
we have to recognize that.

Dr. Perez

I was going to make this comment in a later
session, but I believe that now is the moment. We are all
interested in promoting breastfeeding, but we have to remember
that the breast is one of the most important sexual symbols of a
woman's body. More than that, it is not only a symbol, it is a
very important organ that participates in the sexual union. The
nipple is especially important in a woman's orgasm. Thus, if
somebody proved that it is true that breastfeeding destroys this
symbol, this organ, we would have a great enemy. If it is not
true, we have to teach women that it's not true. I do not know if
it is true or not, but we have to keep in mind that the breast is
not only a place where women produce milk. It is a very important
organ in the sexual relationship of couples.

Dr. Van Esterik

Most of the work that I have been doing this
month at the Bellagio Study Center concentrates on the cultural
construction of women's bodies. I'd like to argue that the breast
is not universally a sexual symbol. It could be buttocks or legs
or other body parts that are considered most attractive about a
woman. But I agree with you in terms of having to consider
breasts as sex objects. Hundreds of years of Cartesian dualisms,
mind versus body, sexuality versus nurturance, maternity is over
here and sexuality is over there. Breastfeeding advocates have a
lot of work to do to show that this is not an either/or
situation. It is both.

A woman was arrested in Ontario for obscene
behaviour for taking her shirt off, and I was an expert witness.
I spent two hours on the stand trying to argue that I could
comment on ordinary breasts, not just lactating breasts. I argued
that men's breasts and nipples are also sexually responsive and
are also important in sexual foreplay, and women have to sit
there and control themselves if a man takes his shirt off, and
it's not considered obscene behaviour. Although there are
differences, the differences must be culturally constructed,
because you can go to beaches in parts of Europe and it's not
shocking, as you mentioned the other day. But a woman
breastfeeding on a nude beach that's what's shocking. Basically,
we have to change the whole way we've been thinking for the last
500 years, so we have a lot of work to do.

Dr. Pollitt

I will play the devil's advocate. In a way, I
don't think what Professor Hanson has presented is social
construction, because there is no cultural constructivism in
immunology or in many other biological aspects of breastfeeding I
worry that if we emphasize the social behavioural component of
breastfeeding too much, where is the seed for cultural
constructivism? There may be a possibility of losing some
strength in the argument of how important breastfeeding is from a
biological perspective, and although I agree with you that one
goes with the other, we must try to evaluate whether, by putting
too much emphasis on cultural construct, we may lose some
strength in the argument for the biological importance of
breastfeeding.

Dr. Van Esterik

I think you have made the biological points
pretty clearly over the last few days.

Dr. Garza

Well, it's brief, but it's important, I hope.
Because we've constructed most of this discussion around changing
behaviours, I'd like you to talk a little about how we protect
the social constructs that exist, because we saw data earlier
showing that 50% to 90% of women are breastfeeding. Thus, we seem
to have a significant advantage in protecting a practice that
does exist. How do we use the cultural constructs that have
maintained this for the last 20 to 25 years?

Dr. Van Esterik

I don't have a clear answer. It is very
important that we work with very local and specific
understandings of infant feeding. We should pay much more
attention to language and linguistic issues within communication
campaigns to ensure we are using the words of the women we want
to influence. In other words, we should put much more emphasis on
the experiences of women themselves. I would hope that these
experiences, in fact, will be parallel discourses. In other
words, the scientific and the biological discourse will be much
better understood if they are related to women's experiences, so
that women's breastfeeding experiences will be much more
prominent. I think these narratives are absolutely critical. I
don't know how they would fit in with your research designs, but
I don't see that they would do any harm as illustrating another
way of thinking alongside the scientific papers on this topic.

Many of the factors that have contributed
to the decline in breastfeeding around the world can be overcome
by education and support. Examples of successful approaches to
education at different levels (mother, health professional,
institution) that impact breastfeeding are discussed. For
example, because breastfeeding is a learned behaviour for both
mother and baby, providing the mother with information, skills,
and support for the breastfeeding process is integral to her
ability to breastfeed successfully. In addition, because the
health professional plays a pivotal role in the success or
failure of breastfeeding it is essential I that education and
training of health professionals be adequately addressed. By
using an approach to healthprofessional education that builds on
a highly trained core and spreads to all levels through a
built-in multiplier effect, improvement of breastfeeding
practices can be assured. In order to sustain these results,
however, health-professional school curricula must include
adequate information on the science of lactation and the clinical
management of breastfeeding The experience of Chile's National
Breastfeeding Programme is used to illustrate the power of
education at each of these levels in influencing the success of
breastfeeding and the feasibility of using education of both
mothers and health professionals as a way of preserving this
incredible natural resource.

Breastfeeding is a learned behaviour

Why does breastfeeding, something so
biological, natural, and part of the essence of being a mammal,
need to be taught and learned? Lactation occurs in every female
after delivery as a biological response to hormones present in
that period, and yet 38,000 infants die every day because they
are not breastfed [1]. Clearly breastfeeding is a behaviour that
needs to be learned for the survival of the species [2].

In nature, young females observe their elders
caring for and breastfeeding their offspring. That experience
will allow them to take care of their own when they reach
reproductive age. A good example of the power of this experience
is the case of a female gorilla named Dolly who had been raised
at the San Diego Zoo. When she delivered her first offspring, she
did not know what to do. She hugged the placenta and was afraid
to touch the baby, whom she was not able to breastfeed. During
her second pregnancy, the curators decided to teach her about
mothering and breastfeeding. They showed her videos of mother
gorillas in the wild nursing their infants and gave her a doll to
teach her to be gentle in holding and nursing a baby. The
teaching programme was a success, and she has been able to nurse
and care for several other babies since then.

Something similar occurs with women in modern
society [3]. With urbanization and the lack of extended families,
most first-time mothers have not seen their mothers or relatives
breastfeeding. Even worse, from everywhere around them they have
been receiving the message that what is normal and modern is
bottle-feeding. As young girls, they are given a doll and bottle
to play with, and their mothers also probably bottle-fed. Formula
companies advertise their products to the public, and for many
women, this is their only source of information regarding infant
feeding [4]. As more deliveries occur in hospitals, more women
are influenced by hospital practices that often interfere with
breastfeeding [1]. There, they do not receive the necessary
support from the health-care team, because health professionals
generally lack the knowledge and skills for good clinical
management of breastfeeding [5]. In addition, an increasing
number of women are working away from their homes and their
infants.

Therefore, the natural behaviour of
breastfeeding is subverted by a variety of forces, as reflected
in the often abysmal rates of prevalence and duration of
exclusive breastfeeding.

Educating women about breastfeeding has
a positive effect on breastfeeding performance

One way to minimize this interference with
breastfeeding is through the education and support of mothers.
Several studies show that providing breastfeeding education for
women has a positive impact on the success of breastfeeding
[6-11]. This impact has been underscored by results achieved at
the Hospital of the Pontifical Catholic University of Chile,
which showed a significant increase in exclusive breastfeeding at
six months post-partum among women who received prenatal group
education [12]. Eighty per cent of 59 women who received prenatal
group education as part of a breastfeeding-promotion programme
completed six months of exclusive breastfeeding versus 65% of the
363 who were part of the same study but did not receive prenatal
group education (p < .003). This effect was even larger among
primiparas, where only 57% of those who did not receive prenatal
group education, versus 94% of those who did, were breastfeeding
exclusively by the end of the sixth month (fig. 1).

These results were obtained in the context of a
prospective study on the impact of a breastfeeding promotion
programme on the duration of exclusive breastfeeding among
lower-middle-class urban women. This study took place in the
hospital and outpatient clinic of the Pontifical Catholic
University in Santiago, Chile [13]. The study included a control
group of 313 mother-infant pairs and an intervention group of 422
mother-infant pairs. Both groups were followed monthly for six
months. Thirty-two per cent of the control group were able to
complete six months of exclusive breastfeeding. This was, in
fact, a relatively high prevalence, because only 2% of infants
that age were exclusively breastfed according to a national
survey carried out by the Ministry of Health in 1986. The higher
prevalence in this population was due to the fact that the
hospital of the Pontifical Catholic University has always
promoted breastfeeding and had rooming-in, and medical and
nursing students are taught that breastfeeding is important.

Before recruiting the study population, there
was a need to develop a comprehensive programme designed to
promote exclusive breastfeeding. The breastfeedingpromotion
programme involved educating all health-care providers at the
institution who take care of mothers and infants; changing
policies that interfere with breastfeeding to make them more
supportive of optimal breastfeeding practices, such as immediate
contact between mothers and infants; delaying supplements or
solid foods until the end of the sixth month if the infant is
growing well; creating a Lactation Clinic to prevent and solve
breastfeeding problems; providing breastfeeding education for
women during the prenatal and postnatal periods, including how to
breastfeed and how to prevent problems; and emphasizing the
effect of exclusive breastfeeding on delaying the return of
fertility and the use of the lactation amenorrhoea method for
child spacing.

After the implementation of the
breastfeedingpromotion programme, 67% of the study population
completed six months of exclusive breastfeeding (fig. 2). The
prevalence has even improved in the broader population cared for
at the hospital of the Pontifical Catholic University after the
institution of the Lactation Clinic and the use of the lactation
amenorrhoea method by an increasing number of women. Education
and support activities were developed for women who work outside
the home. When mothers were taught how to hand-express and store
their own milk and were offered monthly clinical follow-up, 47%
of the working mothers were able to feed their infants
exclusively with their milk for six months, and fewer than 6% of
the 170 motherinfant pairs who were followed weaned before six
months (fig. 3). None of the women in the control group (those
not receiving education and support) who continued to work
completed six months of exclusive breastfeeding. All of this
happened in an institution where the personnel thought they were
already promoting breastfeeding, but the results show that much
more could be done. What made the difference?

Health-professional education is the
cornerstone of improvement in breastfeeding practices

The difference was due to the intensive
education of a core team of health professionals in the science
of lactation and the clinical management of breastfeeding, and
the resulting multiplier effect [14]. Before implementing the
breastfeedingpromotion programme, a multidisciplinary team
composed of a paediatrician and an obstetrician participated in
Wellstart International's lactation management education
programme. During their trip to San Diego for the course that
would initiate their participation in the lactation management
education programme, these professionals, like the hundreds of
others throughout the world who have participated in the
programme, asked themselves, "What can we learn that is new
about breastfeeding and lactation during a whole month?" At
the end of the four-week course, like all the others who have
participated in the programme, they had acquired new knowledge
and skills, shared experiences, and realized that lactation was
such a broad topic that they had only just begun to learn.
Wellstart's lactation management education programme is designed
to develop core resources of expertise that can form the basis of
teaching and promotion programmes at the institutional, national,
and regional levels, using the following approach:

Education of educators. By
recruiting teachers and decision makers who are in
positions to influence institutional or national policy,
the lactation management education programme has included
a built-in multiplier or cascade effect that helps to
ensure the continuation and expansion of the
breastfeeding-related efforts to colleagues and families.

Provision of sound scientific foundation
and clinical expertise. Preparing health-care
professionals to teach others and gain the necessary
respect and recognition from their peers requires a
significant quantity and quality of current,
scientifically sound information and the acquisition of
associated clinical skills.

Selection of multidisciplinary teams.
For breastfeeding promotion and support to be effective,
families must receive coherent and consistent information
from the entire health-care team. The lactation
management education programme brings these disciplines
together as working teams and models this approach within
its own faculty.

In-country (or institutional)
ownership of action plans. The programme focuses on
providing participants with knowledge, skills, and
resources and on assisting them to plan and carry out
programmes of their own design, in their own countries.

Provision of teaching materials.
Participant teams require tools to use and adapt for
their own teaching and promotion efforts. Each team
receives funds to pay for a selection of slides, videos,
books, and a variety of teaching aids. These materials
complement the syllabus, the textbooks, and a collection
of over 1,000 relevant journal articles that become the
basis of a lactation library for their institution.

Provision of follow-up.
Field-based follow-up with an emphasis on
institutionalization and sustainability is an essential
component of the lactation management education
programme. Once the participants have finished the
four-week course, they become "associates" (not
trainees, graduates, or alumni). This terminology
reflects the ongoing, collegial nature of the
relationship.

Factor X-the broader human experience.
The term "factor X" is used to describe an
intangible but essential ingredient of the lactation
management education programme: the attention to detail
and special treatment of participants, which helps lead
to lifelong motivation, close relationships, and a sense
of esprit de corps. There is an important intercultural
exchange and sharing of experiences and memories that are
necessary to balance the rigorous technical and
programmatic curriculum.

The lactation management education programme
has had an impact throughout the world, not so much because of
what it has done, but because of the galvanizing effect its
approach has had on others. By putting essential tools and
resources into the hands of teachers and decision makers, the
programme has served as a catalyst for a powerful multiplier
effect in a number of countries. More than 550 associates from
over 50 countries have participated in the lactation management
education programme. In part because of their participation,
National Breastfeeding Programmes are developing in more than 20
countries, National Training Centres in 13 countries, and
Regional Training Centres in 5 countries. The impact is
particularly great in countries where the UNICEF/WHO
Baby-Friendly Hospital Initiative is under way, and many positive
influences are at work. Chile provides an excellent example of
the effect of health-professional education on breastfeeding. In
October 1990 the results of the research project "The effect
of a breastfeeding promotion program on the fertility of urban
women in Santiago, Chile" [15] were presented in a three-day
breastfeeding course for health professionals. The course was
designed to offer participants basic knowledge on the anatomy and
physiology of the mammary gland, clinical management of
breastfeeding, updated benefits of breastmilk and breastfeeding,
and the relation between fertility and breastfeeding, along with
the results of the above-mentioned project and several others.
Two years later, a questionnaire was sent to the participants to
see if the course had had an impact on their actual practices and
recommendations regarding breastfeeding. The results showed there
were significant increases in clinical practices supporting
breastfeeding, which included teaching the mothers and
supervising breastfeeding techniques. The weaning recommendations
given to mothers, including when to begin weaning foods and milk
supplements and when to complete weaning, reflected a
postponement of over two months compared with earlier practices
(fig. 4) [16].

This course was also the beginning of a process
of creating a critical mass of people with knowledge and interest
in promoting and supporting breastfeeding throughout the country.
By adopting many of the approaches used in the lactation
management education programme, Chile developed its own cascade
effect. In 1992, after the Innocenti Declaration and the World
Summit for Children, the Chilean government created a National
Breastfeeding Commission to develop a National Breastfeeding
Programme. As part of that programme, the Baby-Friendly Hospital
Initiative was launched in Chile with the support of UNICEF. The
main emphasis and activities of the National Breastfeeding
Programme, with the participation of the six Wellstart
associates, have been educating health-professional teams on
breastfeeding and developing teaching materials to help them
disseminate that training. In 1992, 34 professionals, including
teams from three hospitals, participated in the first
Baby-Friendly Hospital Initiative Training for Trainers Workshop.
These teams received teaching materials such as slides, videos,
books, and syllabi to replicate the teaching at their
institutions.. Since then two new workshops have been developed,
attended by 142 new trainers who are now teaching the health
teams in their own and neighbouring institutions.. By the end of
1994, more than 4,500 health workers had been trained throughout
the country in replicated, 18-hour courses (fig. 5). Eleven
hospitals have been designated as Baby-Friendly owing to their
supportive practices for breastfeeding. In 1994 approximately
290,000 infants were born in Chile, with 52,000 of these births
occurring in Baby-Friendly Hospitals.

A national survey carried out at the end of
1993 showed that the prevalence of exclusive breastfeeding at six
months had increased from 2% in 1985 to 25% in 1993 (fig. 6). In
areas of the country where health workers in hospitals and
community clinics have been trained, the percentage of exclusive
breastfeeding at six months is more than 60%. These results show
that there actually was a lack of knowledge among health workers
on how to promote and support breastfeeding [17, 18], and that
when they learn, they change their practices, which then have an
impact on the prevalence and duration of breastfeeding in the
community.

The next step is to make this effort
sustainable and costeffective. The only way to do this is to
change what is taught at the university level and to include the
scientific basis and clinical management of breastfeeding in the
curricula of health-professional schools [19, 20]. This effort
has already begun in many countries. A curriculum guide for
medical, nursing, and nutrition training programmes has been
developed by Wellstart and is beginning to be used in several
universities in the United States, Latin America, and Africa. In
Latin America two subregional workshops were hod for this
purpose, one in Guatemala and another in Paraguay. A national
pre-service curriculum workshop was held in the Pontifical
Catholic University in Chile as the first activity of the
National Breastfeeding Training Centre. The participants included
representatives from schools of medicine, nursing, midwifery,
nutrition, pharmacy, and dentistry from all the Chilean
universities. In Africa a similar process is under way with the
participation of 10 countries in east, central, and southern
Africa.

Heal to-professional education is critical to
making any kind of long-term-change in the way breastfeeding is
promoted, supported, and protected. When health professionals are
convinced that a breastfed child has the best start in life and
really understand how breastfeeding works, they will send the
right messages and give the needed support. Only then will the
impact on the community be sustainable and something as natural
as breastfeeding be preserved.